A nurse is caring for a client who is 3 days postoperative following open heart surgery and will be transferred to the medical-surgical unit. Which of the following information should the nurse plan to include in the verbal report?
The client's dressing change schedule.
The client's level of consciousness.
The client's vital signs from the previous shift.
The client's occupation.
The Correct Answer is B
Choice A rationale:
The nurse should not include the client's dressing change schedule in the verbal report when transferring care to the medical-surgical unit. While this information is important for the client's care, it is not a priority for the receiving unit to know during the immediate transfer. Dressing change schedules can vary based on the type of surgery and wound healing progress, and the medical-surgical unit will focus on the client's overall condition.
Choice B rationale:
The client's level of consciousness is a critical piece of information to include in the verbal report when transferring care. Changes in level of consciousness can indicate neurological deterioration or potential complications, especially after a major surgery like open heart surgery. This information helps the receiving nurses monitor the client's condition closely and respond appropriately if any deterioration occurs.
Choice C rationale:
While reporting the client's vital signs from the previous shift is important, it might not be the most relevant information during the immediate transfer from the postoperative unit to the medical-surgical unit. Vital signs can change rapidly, and the receiving nurses will assess the client's current vital signs upon arrival. Therefore, this information is not the priority for the verbal report.
Choice D rationale:
The client's occupation is not a critical piece of information to include in the verbal report during a transfer from the postoperative unit to the medical-surgical unit. The primary focus of the transfer report should be on the client's immediate postoperative condition, potential complications, and any other information directly related to their current medical status.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Providing the client with information about advance directives is an appropriate intervention. Advance directives are legal documents that allow individuals to communicate their preferences for medical treatment in the event they become unable to make decisions for themselves. Educating the client about the importance and benefits of advance directives empowers them to make informed decisions about their care.
Choice B rationale:
Encouraging the client to contact an attorney to create advance directives is not the primary responsibility of the hospice nurse. While legal assistance might be helpful, the nurse should first ensure that the client understands the concept of advance directives and their significance before suggesting legal involvement.
Choice C rationale:
Informing the client that they will need a relative to witness their advance directives is not accurate. While witnesses are often required when signing legal documents, the specific requirements for advance directives can vary by jurisdiction. It's important for the nurse to provide accurate information and not make assumptions about legal processes.
Choice D rationale:
Telling the client that The Joint Commission requires clients to have advance directives is not accurate. While The Joint Commission emphasizes the importance of patient rights and informed decision-making, it does not mandate that all clients must have advance directives. The decision to create advance directives is a personal choice and should be based on the individual's values and preferences.
Correct Answer is D
Explanation
The correct answer is choice D.
Choice A rationale:
“A client who is in balanced skeletal traction.” This client requires specialized orthopedic knowledge to manage the traction and monitor for complications. A nurse without orthopedic experience may not be familiar with the care required.
Choice B rationale:
“A client who had a total hip arthroplasty 3 days ago.” This client is likely to require specialized post-operative care, including pain management, mobility assistance, and monitoring for complications such as infection or dislocation. These tasks typically require specific orthopedic training.
Choice C rationale:
“A client who has a fractured femur with a new cast.” This client will require specialized care to manage the cast, monitor for complications such as compartment syndrome, and provide pain management. These tasks typically require specific orthopedic training.
Choice D rationale:
“A client who had a right above-the-knee amputation 24 hours ago.” This is the correct answer. While this client will require post-operative care, the care is likely to be similar to the post-operative care provided on a medical unit, such as pain management, wound care, and monitoring for complications. Therefore, a nurse from a medical unit could likely provide appropriate care for this client.
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